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 Engaging Bioethics

Engaging Bioethics: An Introduction with Case Studies draws students into this rapidly changing field, helping
them to actively untangle the many issues at the intersection of medicine and moral concern. Presuming
readers start with no background in philosophy, it offers balanced, philosophically based, and rigorous inquiry
for undergraduates throughout the humanities and social sciences as well as for health care professionals-in-
training, including students in medical school, pre-medicine, nursing, public health, and those studying to
assist physicians in various capacities. Written by an author team with more than three decades of combined
experience teaching bioethics, this book offers

Flexibility to the instructor, with chapters that can be read independently and in an order that fits the
course structure
Up-to-date coverage of current controversies on topics such as vaccination, access to health care, new
reproductive technologies, genetics, biomedical research on human and animal subjects, medically
assisted death, abortion, medical confidentiality, and disclosure
Attention to issues of gender, race, cultural diversity, and justice in health care
Integration with case studies and primary sources
Pedagogical features to help instructors and students, including
Chapter learning objectives
Text boxes and figures to explain important terms, concepts, and cases
End-of-chapter summaries, key words, and annotated further readings
Discussion cases and questions
Appendices on moral reasoning and the history of ethical issues at the end and beginning of
life
An index of cases discussed in the book and extensive glossary/index
A companion website (www.routledge.com/cw/seay) with a virtual anthology linking to key primary
sources, a test bank, topics for papers, and PowerPoints for lectures and class discussion.

Gary Seay is professor of philosophy at Medgar Evers College of the City University of New York.

Susana Nuccetelli is professor of philosophy at St. Cloud State University in Minnesota.

2
Praise for this edition

“Seay and Nuccetelli have done an admirable job of distilling and making accessible a large body of medical
information, complex case law, and philosophical ethics. Their text makes the project of developing
competence and understanding in bioethics a lot less daunting, without simplifying the philosophical and
scientific issues. The book is organized so that instructors can easily design a course around a subset of the
topics covered, and its teaching and learning resources are outstanding. This is the best bioethics textbook I am
aware of, for students and teachers alike.”
Brandon Cooke, Professor and Chair (Philosophy),
Minnesota State University, Mankato

“This is a concise introduction to bioethics that covers a lot of ground. The chapters are sufficiently self-
contained so that the text can be adapted to different course designs, and the boxes and figures throughout are
helpful learning aids. Important cases are discussed but don’t dominate the discussion, so the emphasis remains
on the philosophical arguments and issues.”
William A. Bauer, Teaching Assistant Professor,
North Carolina State University

“Seay and Nuccetelli offer a refreshing and bold approach to bioethics that confronts readers directly, requiring
them to wrestle intimately with the most pressing issues through numerous case studies and a nuanced
analysis of the core concepts and principles. The authors strike a delicate balance between accessibility and
depth, with the results being a text that is eminently readable. This is not easy material, but the authors have
created a text open to readers with little or no philosophical background without sacrificing the complexity
found in these important discussions. They also offer an expansive and up-to-date sourcebook to find primary
sources online in the companion website.”
Scott O’Leary, Assistant Professor, University of Saint Mary

3
Engaging Bioethics
An Introduction with Case Studies

Gary Seay and Susana Nuccetelli

4
First published 2017
by Routledge
711 Third Avenue, New York, NY 10017
and by Routledge
2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN
Routledge is an imprint of the Taylor & Francis Group, an informa business
© 2017 Taylor & Francis
The right of Gary Seay and Susana Nuccetelli to be identified as the authors of this work has been asserted by
them in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this book may be reprinted or reproduced or utilized in any form or by any
electronic, mechanical, or other means, now known or hereafter invented, including photocopying and
recording, or in any information storage or retrieval system, without permission in writing from the publishers.
Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only
for identification and explanation without intent to infringe.
Library of Congress Cataloging-in-Publication Data
Names: Seay, Gary, author. | Nuccetelli, Susana, author.
Title: Engaging bioethics : an introduction with case studies / by Gary Seay and Susana Nuccetelli.
Description: New York, NY : Routledge, 2017. | Includes bibliographical references and index.
Identifiers: LCCN 2016028430 | ISBN 9780415837958 (pbk : alk. paper) | ISBN 9780415837941
(hbk : alk. paper) | ISBN 9780203788707 (ebk)
Subjects: LCSH: Medical ethics. Medical ethics—Case studies.
Classification: LCC R724 .S397 2017 | DDC 174.2—dc23
LC record available at https://lccn.loc.gov/2016028430
ISBN: 9780415837941 (hbk)
ISBN: 9780415837958 (pbk)
ISBN: 9780203788707 (ebk)
Typeset in Minion Pro
by Apex CoVantage, LLC

5
 Contents

About the Authors

Preface
Abbreviations

Part I Bioethics and Moral Theory

Chapter 1 The Study of Morality

Chapter 2 Philosophical Accounts of Morality

Part II Theoretical and Methodological Issues in Bioethics

Chapter 3 Principle-Oriented and Case-Oriented Bioethics

Chapter 4 Managing Patient Information

Chapter 5 Consent with Competence and Without

Part III Moral Issues at the End of Life

Chapter 6 Death and Dying

Chapter 7 When Life Supports Are Futile or Refused

Chapter 8 Medically Assisted Death

Chapter 9 End-of-Life Measures for Severely Compromised Newborns

Part IV Moral Issues at the Beginning of Life

Chapter 10 Personhood in the Abortion Debate

Chapter 11 Abortion in the Typical Case

Chapter 12 Abortion in the Hard Cases

Chapter 13 Conflicts of Rights at Life’s Beginning

Part V The Biotechnological Revolution

Chapter 14 New Reproductive Technologies

6
Chapter 15 Human Genetic Engineering

Part VI Medicine and Society

Chapter 16 Biomedical Research on Animals

Chapter 17 Biomedical Research on Humans

Chapter 18 Justice in Health Care

Appendix A: The Tools of Ethical Inquiry

Appendix B: Evolving Attitudes toward Ending or Preventing Human Life
Glossary/Index
Index of Cases
Additional References

7
 Detailed Contents

About the Authors

Preface
Abbreviations

Part I Bioethics and Moral Theory

Chapter 1 The Study of Morality
1.1 Rev. Jacobson’s Refusal of Vaccination
1.2 The Evolution of Bioethics from Professional Ethics
The Hippocratic Tradition
Medieval Developments
Later Developments
Contemporary Bioethics
1.3 Bioethics in the Context of Ethics
Descriptive and Normative Senses of ‘Morality’
The Philosophical Study of Morality
Normative Ethics
1.4 Chapter Summary
1.5 Study Aids
Key Words
Questions and Cases for Further Consideration
Suggested Readings

Chapter 2 Philosophical Accounts of Morality

2.1 Baby Theresa and the Problem of Anencephalic Organ Sources
2.2 Authority Is the Source of Normativity
Culture as Moral Authority
God as Moral Authority
2.3 Authority Is Not the Source of Normativity
Natural Law Theory
Consequentialism
Kantian Ethics
Virtue Ethics
Care Ethics
Rossian Ethics
Particularism
2.4 Chapter Summary
2.5 Study Aids
Key Words
Questions and Cases for Further Consideration
Suggested Readings

8
Part II Theoretical and Methodological Issues in Bioethics

Chapter 3 Principle-Oriented and Case-Oriented Bioethics

3.1 Dax’s Case
3.2 Principlism
Autonomy
Nonmaleficence
Beneficence and Paternalism
3.3 Casuistry
How Casuistry Works
The Top-Down/Bottom-Up Dichotomy
3.4 Chapter Summary
3.5 Study Aids
Key Words
Questions and Cases for Further Consideration
Suggested Readings

Chapter 4 Managing Patient Information

4.1 The Tarasoff Decision
4.2 Medical Confidentiality
Philosophical Grounds
Absolutism, Universalism, and Skepticism
4.3 Must Health Care Professionals Always Tell the Truth?
Disclosure and Deception Defined
Evolving Attitudes toward Disclosure
Moral Grounds for Disclosure
The Problem of Culture
4.4 Genetic Information
Genetic Knowledge
Genetic Pseudo-Knowledge
Nondirective Genetic Counseling
Is There a Right to Genetic Ignorance?
4.5 Chapter Summary
4.6 Study Aids
Key Words
Questions and Cases for Further Consideration
Suggested Readings

Chapter 5 Consent with Competence and Without

5.1 Natanson v Kline: The Limits of Paternalistic Beneficence
5.2 The Elements of Informed Consent
Consent
Information
Understanding and Voluntariness
Competence
5.3 Exceptions and Doubts
Exceptions to Informed Consent
Skepticism about Informed Consent
5.4 Consent in the Absence of Competence
Decisionmaking for Previously Competent Adults
Decisionmaking for Never Competent Adults

9
 Decisionmaking for Children
Decisionmaking in Ashley X
5.5 Chapter Summary
5.6 Study Aids
Key Words
Questions and Cases for Further Consideration
Suggested Readings

Part III Moral Issues at the End of Life

Chapter 6 Death and Dying

6.1 Was Jahi McMath Dead?
6.2 Accounting for Human Death
Western Thought on Human Death
The Standard Account of Death
6.3 Cardiopulmonary Death
The Cardiopulmonary Criterion
Donation after Cardiac Death
6.4 Brain Death
Disorders of Consciousness versus Brain Death
Whole-Brain versus Brainstem Death
Higher-Brain Death
6.5 Chapter Summary
6.6 Study Aids
Key Words
Questions and Cases for Further Consideration
Suggested Readings

Chapter 7 When Life Supports Are Futile or Refused

7.1 Was Continued Life in Tony Bland’s Best Interests?
7.2 Forgoing Life Supports
Karen Quinlan
Nancy Cruzan
Nancy B
7.3 Medical Futility at the End of Life
What Is Medical Futility?
Types of Futility
The Moral Grounds of Medical Futility
Disagreements about Futility Judgments
7.4 Objections and Alternatives to Medical Futility
The Sanctity-of-Life Doctrine
Ordinary versus Extraordinary Means
7.5 Chapter Summary
7.6 Study Aids
Key Words
Questions and Cases for Further Consideration
Suggested Readings

Chapter 8 Medically Assisted Death

8.1 Dr. Coxs Use of Euthanasia

10
 8.2 Medical Euthanasia
Euthanasia and Other End-of-Life Measures
Types of Euthanasia
Passive versus Active Euthanasia
8.3 Physician-Assisted Suicide
Physician-Assisted Suicide and Voluntary Active Euthanasia
Oregons Death with Dignity Act
Suicide Tourism
8.4 Physician-Assisted Dying: For and Against
Physician-Assisted Dying Is Morally Permissible
Physician-Assisted Dying Is Morally Forbidden
The Dutch Experience
8.5 Chapter Summary
8.6 Study Aids
Key Words
Questions and Cases for Further Consideration
Suggested Readings

Chapter 9 End-of-Life Measures for Severely Compromised Newborns

9.1 Baby Jane Doe: Parental Choice and State Duties
9.2 Decisionmaking Standards for Compromised Newborns
The Baby Doe Regulations
From the Baby Doe Regulations to HCA v Miller
9.3 Prematurity and Low Birthweight
Prematurity
Low Birthweight
The Ethical Issues
9.4 Critical Care for Severely Compromised Newborns
For Providing Critical Care
Against Providing Critical Care
Neonatal Euthanasia
9.5 Chapter Summary
9.6 Study Aids
Key Words
Questions and Cases for Further Consideration
Suggested Readings

Part IV Moral Issues at the Beginning of Life

Chapter 10 Personhood in the Abortion Debate
10.1 Marlise Muñoz: Pregnant but Dead
10.2 Personhood
The Ambiguity of ‘Person’
Criteria of Personhood
Over-Inclusiveness, Under-Inclusiveness, and Speciesism
10.3 The Abortion Debate
Does the Debate Matter?
How to Move Ahead
Personhood in the Abortion Debate
10.4 Chapter Summary

11
 10.5 Study Aids
Key Words
Questions and Cases for Further Consideration
Suggested Readings

Chapter 11 Abortion in the Typical Case

11.1 Roe v Wade: A Compromise on Abortion
11.2 Abortion: Some Facts
What Is Abortion?
The Practice of Abortion
11.3 Against the Moral Permissibility of Abortion
The Sanctity of Life
Developmental Continuity
Kind Essentialism
Potentiality
The Loss of a Valuable Future
11.4 For the Moral Permissibility of Abortion
Skepticism about Fetal Personhood
The Good Samaritan Argument
11.5 Intermediate Views
Early Brain Activity
Organized Cortical Activity
Fetal Interests
11.6 Chapter Summary
11.7 Study Aids
Key Words
Questions and Cases for Further Consideration
Suggested Readings

Chapter 12 Abortion in the Hard Cases

12.1 Sherri Finkbine’s Choices
12.2 Two Hard Cases for Abortion Critics
Abortion to Save the Mother’s Life or Health
Abortion for Fetal Defects
12.3 Two Hard Cases for Abortion Defenders
Abortion for Sex Selection
Late-Term Abortion
12.4 Chapter Summary
12.5 Study Aids
Key Words
Questions and Cases for Further Consideration
Suggested Readings

Chapter 13 Conflicts of Rights at Life’s Beginning

13.1 Deborah Zimmerman: Alcohol Abuse During Pregnancy
13.2 Maternal-Fetal Conflicts
Some Facts about Fetal Harm
Maternal Obligations and Rights
A Dilemma for Public Policy
13.3 Maternal Rights and the State’s Obligations
Abortion Policy in the UK

12
 Abortion Policy in the US
Banning ‘Partial-Birth Abortion’
Restricting Public Funding for Abortion
13.4 Maternal Rights and Conscientious Objectors
Women/Health Care Providers Conflicts
The Duties of Conscientious Objectors
The Referral Problem
13.5 Chapter Summary
13.6 Study Aids
Key Words
Questions and Cases for Further Consideration
Suggested Readings

Part V The Biotechnological Revolution

Chapter 14 New Reproductive Technologies
14.1 Nadya Suleman’s Octuplets
14.2 The Simple Cases
The Simple Case of In-Vitro Fertilization
Fertility Therapy
The Problem of Multiples
14.3 The Complex Cases
Egg Donation, Gestational Surrogacy, and Postmenopausal Motherhood
Some Facts about Egg Donors and Gestational Carriers
Moral Controversies
14.4 Chapter Summary
14.5 Study Aids
Key Words
Questions and Cases for Further Consideration
Suggested Readings

Chapter 15 Human Genetic Engineering

15.1 Designing Deaf Baby
15.2 Some Moral Controversies in Reprogenetics
Preimplantation Genetic Diagnosis
Human Reproductive Cloning
Early Eugenics
15.3 Human Genetic Enhancement
The Posthuman Scenario
Defining ‘Enhancement’
Designer Babies
15.4 Chapter Summary
15.5 Study Aids
Key Words
Questions and Cases for Further Consideration
Suggested Readings

Part VI Medicine and Society

13
Chapter 16 Biomedical Research on Animals
16.1 Dr. Gennarelli’s Head-Injury Study
16.2 The Animal Experimentation Debate
Abolitionism and Its Rivals
The Benefits Argument
Doubts about the Benefits of Animal Research
16.3 Animal Moral Standing
For the Moral Standing of Animals
Speciesism versus Humanism
Skepticism about Animals’ Moral Standing
Animal Law
16.4 Chapter Summary
16.5 Study Aids
Key Words
Questions and Cases for Further Consideration
Suggested Readings

Chapter 17 Biomedical Research on Humans

17.1 The Tuskegee Untreated-Syphilis Study
17.2 Ethical Issues in Research on Human Subjects
Early Ethical Guidelines
What Researchers Owe to Subjects
17.3 Research Using Human Biological Material
The Case of Henrietta Lacks
Ms. Lacks’s Descendants
17.4 Epidemiological and Clinical Research
Epidemiological Research
Randomized Clinical Trials
17.5 Gene Therapy
Therapy or Research?
The Jesse Gelsinger Case
17.6 Research in Developing Countries
The AZT Trials in Sub-Saharan Africa
Cultural Imperialism versus Relativism
Moral Lessons from the AZT Trials
17.7 Chapter Summary
17.8 Study Aids
Key Words
Questions and Cases for Further Consideration
Suggested Readings

Chapter 18 Justice in Health Care

18.1 Shortland v Northland Health: Rationing Is Not Futility
18.2 Allocation of Health Care Resources
Distributive Justice
Priority Setting
Distributive Justice in Organ Transplants
18.3 Access to Health Care
Health Inequalities and Inequities
The Right to Health Care
Universal Coverage

14
18.4 Chapter Summary
18.5 Study Aids
Key Words
Questions and Cases for Further Consideration
Suggested Readings

Appendix A: The Tools of Ethical Inquiry

Moral Judgment
Normative versus Descriptive Judgment
Moral Judgment Characterized
Moral Argument
Deductive and Inductive Reasoning
Concepts and Facts
Moral Principles, Commonsense Morality, and Reflective Equilibrium
Missing Premises and Extended Arguments
Check Your Understanding
Appendix B: Evolving Attitudes toward Ending or Preventing Human Life
Abortion, Infanticide, and Contraception
Euthanasia and Suicide
Glossary/Index
Index of Cases
Additional References

15
 About the Authors

Gary Seay is professor of philosophy at Medgar Evers College of the City University of New York. With
Susana Nuccetelli, he is co-editor of Ethical Naturalism: Current Debates (Cambridge University Press, 2012)
and Themes from G. E. Moore: New Essays in Epistemology and Ethics (Oxford University Press, 2007). He has
served on the American Philosophical Associations Committee on Philosophy and Medicine and was
consulting bioethicist on the Ethics Committee of the New York Hospital Medical Center of Queens.

Susana Nuccetelli is professor of philosophy at St. Cloud State University in Minnesota. Her articles in ethics,
philosophy of language, and Latin American philosophy have appeared in many edited volumes and journals.
She is the author of Latin American Thought: Philosophical Problems and Arguments (Westview Press, 2002).
With Gary Seay, she is the author of How to Think Logically (2e, Pearson, 2012).

16
 Preface

Our view in writing this book represents a departure from the prevailing wisdom about how bioethics should
be taught. For most of the subjects brief history, questions about pedagogy have been mostly cast in terms of
two governing assumptions: first, that it is chiefly medical school students in training to be physicians, along
with some undergraduate pre-med majors, who take courses in bioethics, and, second, that the best way for
these students to understand the central issues of the discipline is through using an anthology of original
sources. But neither of these assumptions any longer applies. Students enrolled in bioethics today are as likely
to be undergraduates in nursing programs or training to be physician-assistants, or physical therapists, as med
school students. And there are better ways to teach these diverse kinds of students than to throw at them a
massive, often expensive, collection of primary sources, culled from various journals in medicine, philosophy,
and law. This textbook borrows whats best of the traditional approachusing case studies and providing
references for original sources onlineand combines it with a clear, student-friendly introduction to the complex
subjects and arguments, including the major moral controversies of 21st-century medicine. The book should
therefore be valuable to students with different backgrounds and who are approaching the ethics of medicine
from numerous angles. There are, of course, already other bioethics textbooks, but, we think, none that cover
so thoroughly and lucidly the major moral controversies of contemporary bioethics as this book does.
Engaging Bioethics offers flexibility to the instructor. It can be used as either a stand-alone textbook or in
combination with one of the major anthologies, as its eighteen chapters, grouped in six parts, unfold in a way
that allows instructors to supplement each topic with readings of original sources. A virtual anthology on the
companion website links to key original sources, further allowing for seamless integration of primary sources.
At the same time, chapters are generally self-contained units, and the topics are presented in a way that
permits instructors to assign them in different sequences according to their needs. For example, instructors
wishing to spend less time on theoretical issues could skip Chapters 1 and 2, and fill in the gaps on moral
theory and methodology as the course unfolds. Instructors who want to devote more time to moral reasoning
may assign Appendix A, while those wishing to cover some of the history of end- and beginning-of-life issues
may assign Appendix B. Throughout, we have aimed at even-handedness in reconstructing facts and
arguments, leaving alternative evaluations for further discussion in the classroom.
Intended for students of introductory courses in bioethics or biomedical ethics, this book assumes no
background in those subjects, or in moral philosophy. Weve tried to make the writing style simple and direct,
with jargon kept to a minimum. Scattered throughout are special-emphasis boxes and figures in which
important points are summarized to help students focus on crucial distinctions and fundamental ideas. Each
chapter opens with a set of learning objectives to frame the chapters goals and a case study to get students
immediately engaged. At the end of each chapter are summaries, key words (bolded throughout on first use,
and defined in a glossary at the end of the book), brief annotated lists of suggested readings, and some
questions and cases for further consideration. Among these, in each chapter, is a case raising a cultural, racial,
or gender issue in medicine, always listed at the end for easy reference. Pedagogical aids at the back of the
book include an index of all cases, a list of major abbreviations, additional bibliographical references, and a
glossary. More tools can be found at the books companion website, with open-access resources for students and
password-protected instructors resources. Instructors resources include a test bank of multiple-choice questions
with answers, topics for papers, and PowerPoint presentations. For students and instructors alike, we have
created a unique virtual anthology, listing original sources that are available electronically through most
university libraries subscriptions to databases. This feature includes links to most of the Suggested Readings
found at the end of each chapter (marked with an asterisk in the chapter and online), as well as additional links
selected from a variety of sources, including professional associations, news items, legislation, blogs,
interviews, podcasts, and videos relevant to the chapter topics. Wherever possible, links are provided via
multiple sources, with stable URLs and/or DOIs. This unique approach allows instructors to teach from a

17
textbook while also supplementing with original sources without the burden of an expensive print anthology,
whether they assign additional readings or use them for research papers or homework assignments.
Finally, two notes about terminology are in order. One concerns the absence of a universally accepted
collective noun for all members of the medical team. For brevity, when possible we have used health care
provider with this comprehensive sense. The other issue concerns our eclectic way to avoid sexist language
throughout. Rather than always including all pronouns (e.g., he/her, his or hers), which can become messy to
read, we simply tried to balance our use of masculine and feminine pronouns or use they/their.
We wish to acknowledge some contributions that have made this a much better textbook, especially those of
our very patient and unfailingly helpful editors at Routledge, Andrew Beck and Alison Daltroy. Special thanks
are due also to Natasha Meed and Josiah Enninga for their technical assistance and to anonymous reviewers
who provided insightful guidance. There are several persons to whom we owe thanks for comments and
assistance with details that helped to shape our views on various topics: Stefan Baumrin, Tony Cunningham,
Jordan Curnutt, Rosamond Rhodes, Alan Seay, and Mark Timmons. Our thanks go also to our students at
Medgar Evers College of the City University of New York and at St. Cloud State University, on whom we tried
earlier drafts of the chapters.

18
 Abbreviations

AMA American Medical Association

ANH Artificial Nutrition and Hydration
AWA Animal Welfare Act
D&X Intact Dilation and Extraction
DCD Donation after Cardiac Death
FLOA Future-Like-Ours Argument
EoL End-of-life Measure
ER Emergency Room
FDA Food and Drug Administration
GP Groningen Protocol
GSA Good Samaritan Argument
HGP Human Genome Project
ICU Intensive Care Unit
QALY Quality-Adjusted Life Years
IRB Institutional Review Board
IVF In-Vitro Fertilization
LST Life-Sustaining Treatment
NICU Neonatal Intensive Care Unit
NRT New Reproductive Technology
PAD Physician-Assisted Dying
PAS Physician-Assisted Suicide
PGD Preimplantation Genetic Diagnosis
PPACA Patient Protection and Affordable Care Act
PVS Permanent Vegetative State
RCT Randomized Clinical Trials
SSA Sex-Selective Abortion
SSS Sliding-Scale Standard
STD Sexually Transmitted Disease
UDD Unified Determination of Death Act
HRC Human Reproductive Cloning
VAE Voluntary Active Euthanasia
VLBW Very Low Birthweight
WHO World Health Organization

19
Part I

Bioethics and Moral Theory

20
1 The Study of Morality

Learning Objectives

In reading this chapter you will

► Identify the historical roots of contemporary bioethics in the development of Western

medicine and its professional ethics.
► Recognize descriptive and normative senses of morality.
► Distinguish philosophical studies of morality from those of the sciences.
► Place bioethics in the landscape of ethics.

This chapter introduces bioethics as a practice and an area of ethics of interest to several disciplines. It does so
by first looking at an early landmark case where protecting public health infringed on an individual liberty to
refuse vaccination. Until the 1970s, such conflicts were resolved by appeal to accepted practice and professional
codes. After briefly reviewing the history of these, the chapter looks closely at bioethics today, outlining its
main branches and relations to other areas of ethics.

21
■ 1.1 Rev. Jacobson’s Refusal of Vaccination
The advantages of vaccination policies to prevent outbreaks of infectious disease are now widely
acknowledged. Yet vaccination has not always been smooth sledding. In 1758 the American Calvinist
theologian Jonathan Edwards died of a smallpox inoculation shortly after his inauguration as president of what
is today Princeton University. Such casualties were not uncommon when vaccinations were first introduced.
The eventual eradication of smallpox and the significant progress that has been made in reducing the threat of
other serious diseases, such as polio and measles, are however among the global, public-health successes of
vaccination. In the US, the moral and legal grounds of vaccination mandates by the state came to be questioned
most forcefully when a smallpox epidemic spread through the Northeast in 1901, causing 773 documented
cases and 97 deaths. The following year Cambridge, Massachusetts reported 2,314 infected individuals, of
whom 284 died. Citing an existing statute, the city’s board of health decided to enforce vaccination against
smallpox for all residents, and stipulated a five-dollar fine for those who failed to comply. Among the
delinquents was the Reverend Henning Jacobson, who refused the vaccine for himself and his son. He had a
previous adverse reaction to it and, more important, thought the ordinance violated his right to care for his
own body in the way he thought best.
The city responded by requesting payment of the fine, which prompted Jacobson to initiate legal action. The
court decided that, under the police power of the state, the city’s ordinance did not violate any liberty rights
guaranteed by the Fourteenth Amendment. Jacobson then appealed to the US Supreme Court, which in 1905
found for the state, emphasizing the Commonwealth’s power to enact and enforce laws aimed at protecting the
public from communicable diseases.

■■■
This was the first ruling by the US Supreme Court concerning the scope of state power in public health law.
More than a century later, vaccination continues to present moral and legal challenges worldwide. In 2009, 5-
year-old Edgar Hernandez, soon to be known as ‘patient zero,’ returned from school one day with symptoms
consistent with ‘swine flu’ (the H1N1-virus infection). The virus was not to remain in his remote Mexican
village. A month later, it afflicted some 1,000 individuals in all parts of the United States. By June, there were
18,000 reported cases. Five months later, the Food and Drug Administration approved the use of H1N1
vaccines, and roughly 61 million Americans were vaccinated within the first three months. Faced with a short
supply of the new vaccine, the State of New York’s Department of Public Health sought to protect hospital
patients, who generally have greater vulnerability to infectious disease, by imposing vaccination mandates for
health care providers. It considered the mandate justified by precedent from state court rulings in previous
cases of mandatory rubella vaccination and annual tuberculosis testing of health care providers. The New York
Times reported that three nurses obtained the mandate’s suspension by questioning the vaccine’s proven
effectiveness.1
They thus won a legal battle but not the moral war. For as health care providers, they faced a moral conflict:
on the one hand, they had the duty to promote their patients’ health; on the other, the exercise of that duty
interfered with their individual liberty interest to refuse vaccination or any other medical treatment. In
Jacobson v Massachusetts, the Supreme Court emphasized that many liberty interests must be limited in
pursuit of the common good because “a community has the right to protect itself against an epidemic of disease
which threatens the safety of its members.”
Controversies over vaccination mandates may result from differing beliefs about the facts, the law, religion,
or morality. Rev. Jacobson questioned the facts—namely, whether

Unvaccinated individuals put the public at an increased risk of contracting smallpox.

The state had the power to enforce vaccination ordinances.
The epidemic would spread according to natural, rather than, Divine plans.

22
But his deepest disagreement with the court concerned the right thing to do, from the moral perspective, when
protecting public health infringes on a person’s liberties. Questions of this sort pertain to bioethics, a practice
and a field of academic inquiry with roots in the development of Western medicine and the professional codes
of health providers.

Image 1.1
©iStockPhoto/Steve Debenport

23
■ 1.2 The Evolution of Bioethics from Professional Ethics
The Hippocratic Tradition
The patient’s right to refuse medical treatment, including vaccination, was generally ignored until the rise of
contemporary bioethics in the 1960s and 1970s. But long before that there were concerns in medicine about
other matters of moral right and wrong, especially in connection with patient welfare. From the very
beginnings of Western medicine in 5th-century Greece, physicians sought to regulate their practice by moral
rules. Those who embraced the teachings of Hippocrates of Kos (ca. 460–370 BCE) hoped their rules would be
adopted by other physicians. In this way, persons of defective character—including quacks and dishonest
schemers of all kinds—might find the calling of medicine too morally rigorous for their taste and be driven
away. The rules of Hippocratic medicine became background assumptions that persisted through more than
20 centuries until the rise of contemporary bioethics. They chiefly concern duties and decorum. Among other
things, Hippocratic doctors pledged to avoid harming their patients, to keep confidential the things revealed to
them in the course of treatment, and to ask as a fee no more than what the patient could reasonably afford to
pay. But they were also expected to cultivate certain traits of character or virtues. Physicians should have a
demeanor of seriousness, scholarliness, dignity, and reserve. They were to be scrupulously honest and polite
with their patients, striving always to bring credit to their profession and to put the patient at ease. In addition,
they were to regard the practice of medicine as a ‘holy’ calling, and hold their mentors in great reverence.
It is striking how many of these ideals persist even today in the mystique of medicine that undoubtedly
contributes to its high social status. And although some Hippocratic duties such as what appears to be a strict
prohibition of both abortion and euthanasia are controversial today, others continue to carry weight in
contemporary bioethics. These include that patients have an obligation to cooperate with their health care
providers, and that physicians have a duty to relieve suffering and should neither try to apply curative
treatment where no cure is possible nor attempt to save from death a patient who cannot be saved.

Medieval Developments
The Influence of Christianity and Maimonides
Over the centuries, a number of other ethical rules have taken hold in the practice of medicine. Some of these
originated in the late Roman period and early Middle Ages owing in part to the influence of Christianity, such
as the duty of medical professionals not to abandon their patients. St. Basil of Cappadocia, probably inspired by
Jesus’ teaching that one must care for the sick, founded the first hospital at Caesarea in 372, where nuns and
monks served as health care providers. Hospitals on this model soon began to spring up all over Christendom.
At the same time, the Hippocratic tradition took on a new moral imperative for physicians: the duty to care for
the sick, putting the patient’s interest first, even when they risked exposure to deadly disease. Later, during the
high Middle Ages, this duty came to be interpreted in Italian commercial cities as a duty of health care
providers not to abandon patients, even in a time of plague, without regard to risk to themselves. Not
surprisingly, the compliance with this new medical duty was uneven. Some were able to muster the courage to
act on it, but many did not. For nurses, such a stringent duty of care had long been taken for granted, a fact
evident later in Florence Nightingale’s criticism of medical professionals who care more about themselves than
about their patients.
In the medieval period, however, the moral influences on Western medical ethics came not only from
Christianity. Jewish scholars also made substantial contributions. Chief among them was the physician and
philosopher Maimonides (1135–1204). His voluminous writings as a Talmudic scholar touch occasionally on
ethics in medicine such as the duties to care for the sick and wounded and to preserve human life whenever
possible. So important was the latter duty, Maimonides thought, that religious duties—even Sabbath
observance—could be suspended, if necessary, to comply with it.

Thomist Ethics

24
Another medieval thinker with influential views on the ethics of medicine was Thomas Aquinas (1225–1274),
the Italian Catholic theologian and philosopher whose writings are the foundations of what’s now called
‘Thomism.’ Thomism sanctions an iron-clad duty of health care professionals to protect and extend human life
whenever possible. In reasoning about this weightiest of moral matters, Thomists think that the intention with
which an action is taken is important in assessing whether the action is morally right or wrong—something
consistent with the common intuition that, for instance, an amputation, normally forbidden on moral grounds
as mutilation, would be right when necessary to remove a gangrenous limb, thereby saving a life.
Thomism also refined casuistry, a method for deciding what to do or believe, morally, about any given case
that’s now preferred by some bioethicists over an alternative method that invokes general principles. Casuist
decisionmaking begins by identifying the morally relevant facts of a case, drawing moral conclusions by
comparing it with similar cases that have been already decided. We consider both methods in Chapter 3. For
now, note that Thomist bioethics continues to be a force today.

Later Developments
Percival’s Medical Ethics
Some new developments occurred at the very beginning of the 19th century. In 1803 an English doctor, Thomas
Percival (1740–1804) of Manchester, introduced the expression ‘medical ethics’ in an influential book with that
title. It was a large-scale treatise dealing with doctors’ duties in four areas: hospitals, the law, the professional
conduct of physicians in private practice, and relations with pharmacists. Physicians have those duties because
they are trusted to act in the best interests of the patient. Their good reputation depends on such public trust,
which must never be betrayed. It is earned through an uncompromising devotion to the patient’s welfare, high
scientific standards, and the benefit physicians bring to society. Doctors must also respect their patients, the
poor and obscure no less than the wealthy and prominent. But they are also paternalistic toward them: the
physician determines what’s in the patients’ best interests, and makes treatment decisions accordingly. We
return to paternalism in Chapter 3.
Percival followed the Hippocratic tradition, not only in assuming paternalism, but also in rejecting strict
veracity as a duty of physicians toward patients. A physician may deceive patients whenever she thinks that
not to know the truth is in their best interest. But his contemporary, John Gregory (1724–1773), a respected
Scottish physician and professor at Edinburgh, took just the opposite view, and over the next century and a
half he was joined by three eminent American medical school professors who wrote on ethical questions in
medicine, Benjamin Rush (1746–1813), Worthington Hooker (1806–1867), and Richard Clarke Cabot (1868–
1939). All argued that doctors have a duty to tell the truth to their patients.
In contemporary bioethics, the trend to favor a strict duty of veracity has grown parallel to the rise of
awareness about respect for patient autonomy, a medical duty also to be considered at some length in Chapter
3. Here, let’s note that this duty correlates with

A patient’s right to make self-regarding decisions about medical treatment freely, without any coercive
interference.

In the English-speaking world, owing partly to the human-rights movements of the 1960s and 70s, and partly
to the efforts of 20th-century bioethicists, respect for patient autonomy now prevails over paternalism.
Protestant theologians Joseph Fletcher (1905–1991) and Paul Ramsey (1914–1988), two especially noteworthy
pioneers of bioethics, were among those who offered influential arguments for this change. The increasing
acceptance of those arguments led to acceptance of the now familiar right of patients to refuse treatment,
including life-saving treatment.

Image 1.2
©iStockPhoto/ericsphotography

25
The 1847 AMA Code
This overview of professional ethics in the history of medicine would be incomplete without mentioning two
more milestones, both in connection with the appearance in 1847 of the first Code of Ethics of the American
Medical Association (AMA). One concerns the Code’s recognition of some significant obligations that patients
owe their doctors, in addition to a long list of duties of physicians—some from the Hippocratic tradition and
Percival’s Medical Ethics, others breaking new ground. The other concerns the Code’s article IV, which
excludes from the profession all who practice nonstandard forms of medicine outside allopathic medicine, the
strictly science-based mainstream of Western medicine. Thus it became a firm rule of medical ethics that
respectable doctors were to have nothing to do with folk ‘healers’ who practiced homeopathic and
naturopathic remedies of various kinds.
This position was defended enthusiastically by Hooker, who thought that physicians therefore had a
professional duty to be scientifically educated in ways appropriate to their specialties. Hooker’s idea was in fact
not really an innovation in bioethics, but acquired new urgency in the 20th century because of the rapid
development of new technologies. It implies that health care professionals have a firm obligation to keep
abreast of the most recent scholarly literature in their specialties and to know about the latest technologies for
treatment. In the early 20th century, Cabot added another dimension to the needed clinical competencies:
health care professionals must be not only highly proficient in the most up-to-date science of their specialties
but also careful to cultivate communication with patients and cooperation of health care teams in the hospital
environment so as to maximize the patient’s chances of recovery.

Contemporary Bioethics
The Emergence of Biomedical Ethics
Bioethics became an independent field in the 1960s and 70s, with medical ethics as one of its main areas of
concern. Among the factors contributing to this development were

Radical changes in the deliverance of health care as hospitals became ‘medical centers’ and health-
insurance-funded medicine became ‘managed care.’
Rapid developments in medical technology that brought unexpected ethical problems. Vastly increased
technical proficiency had in many cases only created new moral quandaries.

26
 Box 1.1 Ethical Rules for Health Care Providers from the History of
Professional Ethics in Medicine

In the decades after World War II, medicine made spectacular advances in scientific knowledge and developed
powerful new technologies for healing. With progress came increasing uncertainty about whether medicine
should always do for a patient all it could do. Did the application of sophisticated technology and invasive
surgery always serve the patient’s best interests? Health care providers began to realize that the use of
medicine’s full armament in the service of healing might actually make some patients worse off—something
scarcely imaginable before.
Philosophers, theologians, and legal scholars interested in such questions joined efforts with physicians,
nurses, and other health care providers in seeking adequate answers. This in turn led to the birth of bioethics as
an interdisciplinary field of inquiry and area of concern within which medical ethics figures prominently.
Hospitals began to set up their own ethics committees to advise health care professionals and administrators
wrestling with moral dilemmas. At the same time, centers of scholarship in the new field of bioethics began to
appear. In the US, notable institutions arose at the Hastings Center in New York, at the University of
Pennsylvania, at the University of Minnesota, and at Georgetown University’s Kennedy Institute of Ethics,
among other locations. In the late 1970s, the Kennedy Institute published an influential work in contemporary
bioethics, Warren Reich’s Encyclopedia of Bioethics. Meanwhile, Georgetown’s Tom Beauchamp and the
University of Virginia’s James Childress brought out their path-breaking book, Principles of Biomedical Ethics.

Bioethics Today

27
While the long history of ethics in the medical profession and the newly crafted professional codes provide us
with some guideposts in the bewildering forest of contemporary bioethics, they do not really explain how
we’re justified in taking one path rather than another when we face a moral quandary. Moral codes, whether
ancient and revered or the most up-to-date, have no power to obligate us unless their rules are well supported
by independent moral reasons. This is where bioethics comes in.
Bioethics is an interdisciplinary area of concern about moral issues that arise in (1) the practice of medicine
and biomedical research, (2) public health policy, and (3) our relationships with nonhuman animals and the
environment. (1) and (2) constitute the parts of bioethics known as biomedical ethics, which focuses on moral
issues in medicine and clinical ethics, biomedical research ethics, and public health ethics.
Among other things, biomedical ethicists advocate for the rights of patients, offer guidance to the health care
community about what interventions are morally obligatory, forbidden, or optional in specific moral dilemmas,
and counsel health care officials on morally sound public health policies. They also grapple with theoretical
questions concerning the moral reasons for and against certain medical interventions at the end of life, or at its
beginning, such as euthanasia and abortion, professional duties in medicine such as truth-telling and
confidentiality, and policies for the allocation of scarce medical resources such as organs and access to
intensive care.
Note that, although biomedical ethics is only one part of bioethics, here we’ll follow the common practice of
using ‘bioethics’ and ‘biomedical ethics’ interchangeably. Either way, bioethics as a field of inquiry is
interdisciplinary, because it includes elements of philosophy, medicine, theology, the social sciences, and the
law. Its main tools are

Reasoned argument and conceptual analysis (from philosophy).

Scientifically rooted information about the facts of human physiology and the healing arts (from
medicine).
Knowledge of cultural and religious traditions (from theology and the social sciences).
Careful consideration of legal decisions in landmark cases involving bioethical questions (from the
law).

The issues and arguments of bioethics have roots of two kinds: some have emerged in the history of medicine,
others as a result of contemporary reflection about moral right and wrong in the practice of medicine. The
chapters to follow will take up each of these foundations in turn.

Figure 1.1 Bioethics as a Field of Inquiry

28
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